Front Panel Painting “LIFE” By William T Chua MD

Many clinical trials have demonstrated that antiplatelets reduce stroke risk after TIA or minor
stroke by 18% to 41%. RCTs on antiplatelet drugs that reduce stroke, either alone or as part of a
composite of vascular outcomes, include aspirin, dipyridamole, aspirin-dipyridamole
6-8
combination, clopidogrel, cilostazol and triflusal. Although some studies limited subjects to
those with minor strokes instead of TIA, it is reasonable to consider a similar prophylactic effect
10,11
in TIA patients. Based on cost-effective studies, aspirin remains the first option unless there
are contraindications. For guide on the choice of antiplatelets to use, please see the appendix
below on management for stroke prevention.
E. Recommendations:
Many of the recommendations given are adopted from current guidelines of the American
Heart Association and the Canadian best practice recommendations for stroke care which the
SSP deemed applicable to the local setting. 3
TIA and AF
1. Efforts to increase public awareness and that of health workers regarding TIA and its
significance should be maximized.
2. TIA should be treated with urgency due to increase risk for stroke. Patients with
suspected TIA should be evaluated as soon as possible after an event to establish the
diagnosis, rule out stroke mimics and develop a plan of care (AHA Class I, Level of
Evidence B).
3. The use of standardized risk stratification tool at the initial point of health care
contact should be used to guide the triage process of how urgent workup should be
done (Evidence Level B).
4. Patients with TIA should preferably undergo neuroimaging evaluation within 24
hours of symptom onset. MRI, including DWI, is the preferred brain diagnostic
imaging modality. If MRI is not available, head CT should be performed (AHA,
Class I, Level of Evidence B).
5. Evaluation of TIA should be attempted to define cause and determine prognosis and
treatment. TIA patients should be expeditiously evaluated for vascular and cardiac
risk factors for stroke. Hypertension, hyperlipidemia, diabetes, carotid and
intracranial stenosis and other modifiable risk factors should be treated, as outlined in
these guidelines.
6. The following investigations should be undertaken routinely for patients with
suspected transient ischemic attack or minor stroke: complete blood count,
electrolytes, renal function, cholesterol level, glucose level, and electrocardiography
(Evidence Level C).
7. All risk factors for cerebrovascular disease must be aggressively managed, through
both pharmacologic and nonpharmacologic means, to achieve optimal control
(Evidence Level A). While evidence for the benefit of modifying individual risk
factors in the acute phase is lacking, there is evidence of benefit when adopting a
comprehensive approach, including antihypertensives and statin medication.
8. All patients with transient ischemic attack not on an antiplatelet agent at time of
presentation should be started on antiplatelet therapy immediately after brain
imaging has excluded intracranial hemorrhage (Evidence Level A).
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